Abstract
Background and AimsDespite well documented disparities in health and healthcare in rural communities, evidence in relation to quality improvement (QI) interventions in those settings is still lacking. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success.MethodsWe conducted a systematic review and meta-analysis. Systematic electronic searches were conducted in MEDLINE, EMBASE, CINAHL, and 12 additional bibliographic sources. Experimental studies carried out in the OECD member countries assessing the effectiveness of QI interventions aiming to improve diabetes care in rural areas were included. The effect of the interventions and their impact on glycated hemoglobin was pooled using a random-effects meta-analysis.ResultsTwenty-six studies assessing the effectiveness of twenty QI interventions were included. Interventions targeted patients (45%), clinicians (5%), the health system (15%), or several targets (35%), and consisted of the implementation of one or multiple QI strategies. Most of the interventions produced a positive impact on processes of care or diabetes self-management, but a lower effect on health outcomes was observed. Interventions with multiple strategies and targeting the health system and/or clinicians were more likely to be effective. Six QI interventions were included in the meta-analysis (1,496 patients), which showed a significant reduction in overall glycated hemoglobin of 0.41 points from baseline in those patients receiving the interventions (95% CI -0.75% to -0.07%).ConclusionsThis work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patient-oriented interventions.
Highlights
Diabetes mellitus type 2 (DM2) is fast becoming the epidemic of the 21st century, being currently listed as the ninth cause of death worldwide [1]
Access to diabetes specialists is scarcer in rural centers [14], and general practitioners are less likely to adhere to standards of DM2 care [15,16]
The main goals of this systematic review were to assess the effectiveness of quality improvement (QI) strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success
Summary
Diabetes mellitus type 2 (DM2) is fast becoming the epidemic of the 21st century, being currently listed as the ninth cause of death worldwide [1]. Evidence have already been found for disparities in healthcare provision in rural areas, with worsened health outcomes including poorer glycemic control, worse lipid profiles, and higher blood pressure [11]. Those disparities seem to be mainly explained by the lack of an infrastructure capable of sustaining the processes required to improve care and outcomes. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patientoriented interventions
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